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Objectives: In the United States, all men who have sex with men (MSM) were banned from donating blood from 1985 through 2015. In 2016, the guideline was amended such that men who had sexual contact with other men within the previous 12 months could not donate blood. We aimed to identify blood donation practices and their relationship with HIV risk and testing among young adult MSM (YMSM) at risk for having HIV. Methods: In 2014, we recruited HIV-negative non-Hispanic black, Hispanic, and non-Hispanic white YMSM aged 18-24 from across the United States through social media platforms to complete an online survey. Among these YMSM who previously donated blood, we conducted a secondary analysis examining the relationship between having donated blood within the past 12 months and sexual risk behavior from recent condomless anal intercourse (CAI), HIV testing, and self-perceived risk of having an undiagnosed HIV infection. Results: Of the 2261 YMSM surveyed, 1104 (48.8%) had ever previously donated blood and 305 (13.5%) had donated blood within the past 12 months. Of the 305 blood donors, 50 (16.4%) had ever had CAI before their most recent blood donation. Among YMSM who donated blood, past–12-month blood donation was more likely among YMSM who never had CAI (adjusted odds ratio [aOR] = 1.84; 95% confidence interval [CI], 1.24-2.73) than among YMSM who had CAI and more likely among YMSM who believed it was not possible at all that they had an undiagnosed HIV infection (aOR = 1.57; 95% CI, 1.14-2.16) than among YMSM who believed there was any possibility of having an undiagnosed HIV infection; it was not related to past–12-month HIV testing. Conclusions: YMSM donated blood frequently, suggesting that the deferral process in place did not prevent YMSM from donating blood. The current donor screening process should be reconsidered if it is to prevent YMSM from donating blood. Future research could identify screening questions that permit YMSM with a low risk of HIV infection to donate blood while maintaining the safety of the blood supply. [ABSTRACT FROM AUTHOR]

Discordance between self-perceived HIV risk and actual risk-taking may impede efforts to promote HIV testing among young adult men-who-have-sex-with-men (YMSM) in the United States (US). Understanding the extent of, and reasons for, the discordance of HIV risk self-perception, HIV risk-taking and voluntary HIV testing among black, Hispanic and white YMSM could aid in the development of interventions to increase HIV testing among this higher HIV risk population. HIV-uninfected 18–24-year-old black, Hispanic, and white YMSM were recruited from across the US through multiple social media websites. Participants were queried about their voluntary HIV testing history, perception of currently having an undiagnosed HIV infection, and condomless anal intercourse (CAI) history. We assessed the association between previous CAI and self-perceived possibility of currently having an HIV infection by HIV testing status using Cochran-Mantel-Haenszel testing. Of 2275 black, Hispanic and white social media-using 18–24 year-old YMSM, 21% had never been tested for HIV voluntarily, 87% ever had CAI with another man, 77% believed that it was perhaps possible (as opposed to not possible at all) they currently could have an undiagnosed HIV infection, and 3% who reported CAI with casual or exchange partners, but had not been tested for HIV, self-perceived having no possibility of being HIV infected. Of 471 YMSM who had not been HIV tested, 57% reported CAI with casual or exchange partners, yet self-perceived having no possibility of being HIV infected. Per the Cochran-Mantel-Haenszel test results, among those reporting HIV risk behaviors, the self-perception of possibly being HIV-infected was not greater among those who had never been tested for HIV, as compared to those who had been tested. Future interventions should emphasize promoting self-realization of HIV risk and translating that into seeking and accepting voluntary HIV testing among this higher HIV risk population. [ABSTRACT FROM PUBLISHER]

Most previous brief intervention (BI) studies have focused on alcohol or drug use, instead of both substances. Our primary aim was to determine if an alcohol- and drug-use BI reduced alcohol use and increased alcohol treatment services utilization among adult emergency department (ED) patients who drink alcohol and require an intervention for their drug use. Our secondary aims were to assess when the greatest relative reductions in alcohol use occurred, and which patients (stratified by need for an alcohol use intervention) reduced their alcohol use the most. In this secondary analysis, we studied a sub-sample of participants from the Brief Intervention for Drug Misuse in the Emergency Department (BIDMED) randomized, controlled trial of a BI vs. no BI, whose responses to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) indicated a need for a BI for any drug use, and who also reported alcohol use. Participants were stratified by their ASSIST alcohol subscore: 1) no BI needed, 2) a BI needed, or 3) an intensive intervention needed for alcohol use. Alcohol use and alcohol treatment services utilization were measured every 3 months for 12 months post-enrollment. Of these 833 participants, median age was 29 years-old, 46% were female; 55% were white/non-Hispanic, 27% black/non-Hispanic, and 15% Hispanic. Although any alcohol use, alcohol use frequency, days of alcohol use, typical drinks consumed/day, and most drinks consumed/day decreased in both the BI and no BI arms, there were no differences between study arms. Few patients sought alcohol use treatment services in follow-up, and utilization also did not differ by study arm. Compared to baseline, alcohol use reduced the most during the first 3 months after enrollment, yet reduced little afterward. Participants whose ASSIST alcohol subscores indicated a need for an intensive intervention generally had the greatest relative decreases in alcohol use. These results indicate that the BI was not efficacious in reducing alcohol use among alcohol- and drug-using adult ED patients than the self-assessments alone, but suggest that self-assessments with or without a BI may confer reductions in alcohol use. [ABSTRACT FROM AUTHOR]

Young adult men-who-have-sex-with-men (YMSM) continue to have among the highest incidence of HIV infection in the United States. Pre-exposure prophylaxis (PrEP) is an effective and safe method of preventing HIV infection; however, despite US Food and Drug Administration approval, utilization remains low, in part, due to structural barriers, particularly access to healthcare. In this study, we used social media to recruit black, Hispanic, and white HIV-uninfected 18- to 24-year-old YMSM. Participants completed an online survey about their sexual behavior, healthcare access, and previous use of PrEP. Of the 2297 YMSM surveyed, only 3.4% had used PrEP. PrEP use was associated with higher levels of education, living alone, older age, higher levels of sexual activity, and greater healthcare access, specifically having healthcare insurance and a clinic or primary care provider (PCP) from whom they received care. Among PrEP nonusers, 65% met at least one of the US Centers for Disease Control and Prevention recommended indications for PrEP use, and of these, 59% had healthcare insurance and received care in a clinic and/or had a PCP. Multi-variable multi-nomial logistic regression modeling identified disparities in access to healthcare by age, race/ethnicity, education, and region. Specifically, older YMSM, blacks and Hispanics, those with fewer years of formal education, and residents of the southern and the western United States were more likely to lack healthcare access. These results demonstrate both potential opportunities and barriers to the scale-up of PrEP among YMSM. [ABSTRACT FROM AUTHOR]

Introduction: Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed. Methods: We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18-64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST. Results: Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies. Conclusion: Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions. [ABSTRACT FROM AUTHOR]

Community outreach efforts to increase HIV pre-exposure prophylaxis (PrEP) utilization by at-risk men who have sex with men (MSM) first need to elucidate preferences for learning about PrEP and linking to PrEP resources. In this pilot study, we observed that among MSM recruited through community outreach, HIV sexual risk-taking was significant, yet self-perceived PrEP knowledge was low and interest in learning more about PrEP was moderate. Most preferred learning about PrEP and being provided local PrEP clinic information through electronic media. However, receipt of PrEP information alone did not appear to motivate these men into presenting to a local clinic for PrEP evaluation. [ABSTRACT FROM PUBLISHER]

The article discusses the implication of providing information to patients regarding costs of emergency department routine HIV screening tests in the U.S., based on a survey among patients at Albany Medical Center in New York City from June 2013 through July 2014. The variables cited in the survey include demographic characteristics, willingness of patients to have an HIV test, and percentage of patients with health care insurance. An expert working group was convened to assist HIV patients.

In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in health-care settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission. It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This study estimated the extent of HIV testing in US emergency departments (EDs), outpatient ambulatory medical care departments (OPDs), and physician offices among 13- to 64-year-olds from 1992 to 2010 to determine their responsiveness to CDC recommendations to expand HIV testing. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. Over the entire study period, HIV testing was significantly greater in OPDs than in EDs (p< 0.01) and physician offices (p< 0.01). Multivariable logistic regression analysis showed that Hispanic and Black patients and those receiving Medicaid were more likely to be tested for HIV. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing at EDs (Odds ratios [OR] 1.00 [0.97–1.03]) or OPDs (OR 1.01 [0.98–1.04]). For physician offices, there was no change in HIV testing for 1993–1999 (OR 1.03 [0.99–1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02–1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval years after revised CDC HIV testing recommendations were released for 1993–2001, 2002–2006, and 2007–2010. [ABSTRACT FROM AUTHOR]

In 1993, 2001, and 2006, the US Centers for Disease Control and Prevention (CDC) released revised recommendations aimed to expand HIV screening in health-care settings, increase the number of people who are aware of their infection, improve the health of those who are infected, and reduce HIV transmission. It is unclear how responsive health-care settings have been on a national level to these three successively revised sets of CDC recommendations. This study estimated the extent of HIV testing in US emergency departments (EDs), outpatient ambulatory medical care departments (OPDs), and physician offices among 13- to 64-year-olds from 1992 to 2010 to determine their responsiveness to CDC recommendations to expand HIV testing. The report includes data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS), which are national probability sample surveys conducted by the National Center for Health Statistics (NCHS) for CDC. Over the entire study period, HIV testing was significantly greater in OPDs than in EDs (p< 0.01) and physician offices (p< 0.01). Multivariable logistic regression analysis showed that Hispanic and Black patients and those receiving Medicaid were more likely to be tested for HIV. Logistic regression tests of trend for the entire study period did not demonstrate significant increases in testing at EDs (Odds ratios [OR] 1.00 [0.97–1.03]) or OPDs (OR 1.01 [0.98–1.04]). For physician offices, there was no change in HIV testing for 1993–1999 (OR 1.03 [0.99–1.06]), but there was a relative increase for the entire study period (OR 1.04 [1.02–1.06]) because of more HIV testing in 2009 and 2010 in this setting. However, there were no differences in HIV testing for each setting for the interval years after revised CDC HIV testing recommendations were released for 1993–2001, 2002–2006, and 2007–2010. [ABSTRACT FROM PUBLISHER]

The Emergency Department (ED) appears to be an ideal place to conduct hepatitis C virus (HCV) screening. We aimed to estimate the prevalence of prior HCV test positivity among adult (18-64 year-old) patients at The Miriam Hospital and Rhode Island Hospital EDs, as well as the undiagnosed HCV antibody seroprevalence among patients with any self-reported injection or non-injection drug use who agreed to undergo rapid HCV antibody testing. The prevalence of prior HCV test positivity among 8,500 adult ED patients was approximately 4.6%, and the previously undiagnosed HCV antibody seroprevalence among 621 drug-using adult ED patients was 1.6%. Among the ten ED patients with a positive rapid HCV antibody test not previously diagnosed, eight were born after 1965 and six never had injected drugs. If current HCV screening recommendations were followed exclusively in this setting, this practice would have missed half of those with a positive rapid HCV antibody test. [ABSTRACT FROM AUTHOR]

This article provides an assessment over time of the incidence of newspaper-reported Internet-initiated sexual assaults among U.S. adolescents undergoing adjudication from 1996 to 2007. Of 812 newspaper reports of adjudicated Internet-initiated sexual assault, most (79.2%) victims were female, and the median age was 14 years. The incidence rate of these reports increased over the 12-year period for females but remained steady for males. The frequency of these assaults was much less than reported for other types of sexual assaults in this age group. These estimates hopefully will assist in a greater understanding of these assaults, aid in interventions to decrease their occurrence, and guide effective policymaking that will reduce all types of sexual assault among adolescents. [ABSTRACT FROM AUTHOR]

Because reliance on patients' self-perceived risk for HIV might mislead emergency department (ED) clinicians on the need for HIV testing, we aimed to measure congruency between self-perceived and reported HIV risk in a traditional lower prevalence, lower-risk cohort. A random sample of 18- to 64-year-old patients at a large academic urban ED who were by self-report not men-who-have-sex-with-men (MSM) or injection-drug users (IDUs) were surveyed regarding their self-perceived and reported HIV risk. Sixty-two percent of participants were white non-Hispanic, 13.8% Black, and 21.2% Hispanic; and 66.9% previously had been tested for HIV. Linear regression models were constructed comparing self-perceived to reported HIV risk. Among the 329 female ED patients, 50.5% perceived that they were 'not at risk' for HIV, yet only 10.9% reported no HIV risk behaviors, while among the 175 male ED patients, 50.9% perceived that they were 'not at risk' for HIV, yet only 12.6% reported no HIV risk behaviors. Only 16.9% of women and 15.7% of men who had no self-perceived risk for HIV also reported no HIV risk behaviors. Multivariable linear regression demonstrated a weak relationship between self-perceived and reported risk. Congruency between self-perceived risk and reported HIV risk was low among these non-MSM, non-IDU ED patients. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) patients comprise a high-risk population for alcohol misuse and sexual risk for HIV. In order to design future interventions to increase HIV screening uptake, we examined the interrelationship among alcohol misuse, sexual risk for HIV and HIV screening uptake among these patients. Methods: A random sample of 18-64-year-old English- or Spanish-speaking patients at two EDs during July-August 2009 completed a self-administered questionnaire about their alcohol use using the Alcohol Use Questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the HIV Sexual Risk Questionnaire. Study participants were offered a rapid HIV test after completing the questionnaires. Binging (⩾ five drinks/occasion for men, ⩾ four drinks for women) was assessed and sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, dependence) were calculated using AUDIT scores. Analyses were limited to participants who had sexual intercourse in the past 12 months. Multivariable logistic regression was used to assess the associations between HIV screening uptake and (1) alcohol misuse, (2) sexual risk for HIV, and (3) the intersection of HIV sexual risk and alcohol misuse. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics and separate models for men and women were constructed. Results: Of 524 participants (55.0% female), 58.4% identified as white, non-Hispanic, and 72% reported previous HIV testing. Approximately 75% of participants reported drinking alcohol within the past 30 days and 74.5% of men and 59.6% of women reported binge drinking. A relationship was found between reported sexual risk for HIV and alcohol use among men (AOR 3.31 [CI 1.51-7.24]) and women (AOR 2.78 [CI 1.48-5.23]). Women who reported binge drinking were more likely to have higher reported sexual risk for HIV (AOR 2.55 [CI 1.40-4.64]) compared to women who do not report binge drinking. HIV screening uptake was not higher among those with greater alcohol misuse and sexual risk among men or women. Conclusions: The apparent disconnection between HIV screening uptake and alcohol misuse and sexual risk for HIV among ED patients in this study is concerning. Brief interventions emphasizing these associations should be evaluated to reduce alcohol misuse and sexual risk and increase the uptake of ED HIV screening. [ABSTRACT FROM AUTHOR]

Objectives. CDC 2006 recommendations for new HIV testing methods in U.S. health-care settings (opt-out approach, general medical consent, and optional prevention counseling) have been the subject of a public ethical debate. Ethical concerns might limit their implementation and affect expanded HIV screening efforts. We compared clinicians' and patients' perspectives on the ethical concerns raised about, justifications provided in support of, and preferences for the 2006 CDC-recommended HIV testing methods for the U.S. health-care setting, in contrast with the 2001 CDC-recommended HIV testing methods (opt-in approach, specific written consent, and mandatory prevention counseling). Methods. We conducted a non-inferiority trial and survey of 249 clinicians and random samples of 1,013 of their patients at three emergency departments and three ambulatory care clinics at university-affiliated hospitals in Rhode Island from June to December 2007. Results. Clinicians found the 2006 CDC HIV testing methods to be more ethically concerning than the 2001 testing methods (i.e., ethically inferior), while patients had few ethical concerns. In regard to ethical justifications cited for the 2006 CDC HIV testing methods, clinicians were more supportive of the ethical justifications cited for using an opt-out approach and general medical consent, while patients were more supportive of the justifications for optional HIV prevention counseling. Clinicians showed a relatively greater preference for the opt-out approach and use of general medical consent, while patients had a relatively greater preference for optional HIV prevention counseling. Conclusions. Clinicians and their patients hold divergent ethical perspectives on CDC's 2006 HIV testing methods. The results indicate an opportunity to review not only these but also future HIV testing recommendations, as well as how they are presented for implementation. [ABSTRACT FROM AUTHOR]

Objectives. CDC 2006 recommendations for new HIV testing methods in U.S. health-care settings (opt-out approach, general medical consent, and optional prevention counseling) have been the subject of a public ethical debate. Ethical concerns might limit their implementation and affect expanded HIV screening efforts. We compared clinicians' and patients' perspectives on the ethical concerns raised about, justifications provided in support of, and preferences for the 2006 CDC-recommended HIV testing methods for the U.S. health-care setting, in contrast with the 2001 CDC-recommended HIV testing methods (opt-in approach, specific written consent, and mandatory prevention counseling). Methods. We conducted a non-inferiority trial and survey of 249 clinicians and random samples of 1,013 of their patients at three emergency departments and three ambulatory care clinics at university-affiliated hospitals in Rhode Island from June to December 2007. Results. Clinicians found the 2006 CDC HIV testing methods to be more ethically concerning than the 2001 testing methods (i.e., ethically inferior), while patients had few ethical concerns. In regard to ethical justifications cited for the 2006 CDC HIV testing methods, clinicians were more supportive of the ethical justifications cited for using an opt-out approach and general medical consent, while patients were more supportive of the justifications for optional HIV prevention counseling. Clinicians showed a relatively greater preference for the opt-out approach and use of general medical consent, while patients had a relatively greater preference for optional HIV prevention counseling. Conclusions. Clinicians and their patients hold divergent ethical perspectives on CDC's 2006 HIV testing methods. The results indicate an opportunity to review not only these but also future HIV testing recommendations, as well as how they are presented for implementation. [ABSTRACT FROM AUTHOR]

Objective: Our goal was to gain a better understanding of the femoral vessel anatomy as it relates to central venous cannulation. The primary objective of this study was to use bedside ultrasonography to determine the amount of exposed femoral vein at three sites corresponding to surface anatomy of the landmark-based procedure. Methods: This cross-sectional study enrolled a random sample of 180 adult patients presenting to a large urban academic emergency department. Subjects underwent standardized ultrasonography to identify and measure the depth and diameter of the femoral vessels and amount of exposed femoral vein at the level of the inguinal ligament (0 cm) 2 cm and 4 cm below. Repeated measures analysis of variance was used to determine significant relationships between vessel measurements and distance from the inguinal ligament. Results: The median age was 44.5 (range 19-90) years; 101 patients were male. The mean (± SD) percentage of exposed vein at the inguinal ligament was 83% (± 21). This decreased significantly (p < 0.01) with increasing distance from the inguinal ligament: 65% (± 25) at 2 cm and 56% (± 30) at 4 cm. At every distance away from the inguinal ligament, there were some subjects with no vein exposed. Conclusion: This study demonstrates significant overlap of the femoral vessels at sites where landmark-based femoral vein cannulation is often attempted. Our results suggest that ultrasound guidance would be beneficial as femoral vein cannulation may be difficult or impossible in certain individuals owing to anatomic variations. [ABSTRACT FROM AUTHOR]

Objective To determine the proportion of emergency department (ED) patients who have been tested for human immunodeficiency virus (HIV) infection and assess if patient history of HIV testing varies according to patient demographic characteristics. Design From July 2005-July 2006, a random sample of 18-55-year-old English-speaking patients being treated for sub-critical injury or illness at a northeastern US ED were interviewed on their history of HIV testing. Logistic regression models were created to compare patients by their history of being tested for HIV according to their demography. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. Results Of 2107 patients surveyed who were not known to be HIV-infected, the median age was 32 years; 54% were male, 71% were white, and 45% were single/never married; 49% had private health-care insurance and 45% had never been tested for HIV. Of the 946 never previously tested for HIV, 56.1% did not consider themselves at risk for HIV. In multivariable logistic regression analyses, those less likely to have been HIV tested were male (OR: 1.32 [1.37-2.73]), white (OR: 1.93 [1.37-2.73]), married (OR: 1.53 [1.12-2.08]), and had private health-care insurance OR: 2.10 [1.69-2.61]). There was a U-shaped relationship between age and history of being tested for HIV; younger and older patients were less likely to have been tested. History of HIV testing and years of formal education were not related. Conclusion Almost half of ED patients surveyed had never been tested for HIV. Certain demographic groups are being missed though HIV diagnostic testing and screening programmes in other settings. These groups could potentially be reached through universal screening. [ABSTRACT FROM AUTHOR]

The objectives of this study were to estimate the incidence and identify the temporal patterns of visits to Rhode Island emergency departments (EDs) by adults who were sexually assaulted. Visits to all Rhode Island EDs from January 1995–June 2001 by adults who were sexually assaulted were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) codes. Medical records of these visits were reviewed. Frequency distributions of the assault characteristics and patient demographics were generated. Incidence rates (IRs) of ED visits after sexual assault were estimated using 2000 US Census data. Analyses of the temporal patterns of the ED visits after sexual assault were conducted. Of the 823 ED visits, 796 (96.7%) were by females and 27 (3.3%) were by males. The median age for females was 25 years (range, 18–96 years) and was 28 years (range, 18–87 years) for males. Among the female patients, 76.6% sustained a vaginal/anal assault. Among the male patients, 59.3% sustained an anal assault. The average annual IR of ED visits after sexual assault was 30.3/100,000/year for females and 1.2/100,000/year for males, which is a 25-fold greater incidence of these visits for females than males. ED visits after adult sexual assault were more frequent during warmer months and around 5 p.m. There was a gradual 43% increase in the IRs of ED visits after sexual assault over the 6.5-year period. These findings should help direct EDs to maximize supportive services when they are needed most often. [ABSTRACT FROM AUTHOR]

Objectives. We assessed emergency department (ED) patient acceptance of opt-in, rapid human immunodeficiency virus (HIV) screening and identified demographic characteristics and HIV testing-history factors associated with acceptance of screening. Methods. A random sample of 18- to 55-year-old ED patients was offered rapid HIV screening. Patient acceptance or decline of screening and the reasons for acceptance or decline were analyzed with multivariable regression models. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated for the logistic regression models. Results. Of the 2,099 participants, 39.3% accepted HIV screening. In a multinomial regression model, participants who were never married/not partnered, did not have private health insurance, and had 12 or fewer years of education were more likely to be screened due to concern about a possible HIV exposure. In a multivariable logistic regression model, the odds of accepting screening were greater among those who were younger than 40 years old (OR = 1.61, 95% CI 1.32, 2.00), nonwhite (OR = 1.28, 95% Cl 1.04, 1.58), not married (OR = 1.82, 95% Cl 1.44, 2.28), lacking private health insurance (OR = 1.40, 95% CI 1.13, 1.74), and who had 12 or fewer years of education (OR = 1.43, 95% CI 1.16, 1 .75). Despite use of a standardized protocol, patient acceptance of screening varied by which research assistant asked them to be screened. Patients not previously tested for HIV who were white, married, and 45 years or older and who had private health insurance were more likely to decline HIV screening. Conclusions. In an opt-in, universal, ED HIV screening program, patient acceptance of screening varied by demography, which indicates that the impact of such screening programs will not be universal. Future research will need to determine methods of increasing uptake of ED HIV screening that transcend patient demographic characteristics, HIV testing history, and motivation for testing. [ABSTRACT FROM AUTHOR]

Objectives: To determine how often sexually assaulted adult female emergency department (ED) patients are being offered testing and prophylaxis for sexually transmitted diseases (STDs) and pregnancy and identify factors associated with the offering of tests and prophylaxis. Methods: This is a retrospective study of ED visits for adult female sexual assault in all Rhode Island EDs from January 1995 through June 2001. The percentage of patients offered testing and prophylaxis was calculated. Multivariable logistic regression was used to identify factors related to testing and prophylaxis use for women sustaining an anal/vaginal assault. Results: Of the 780 patients, 78.2% sustained anal/vaginal penetration, 5.0% genital touching only, and 3.7% oral sex only, and 13.1% did not know what happened to them. Of those women anal/vaginally assaulted, 83.8% were offered chlamydia/gonorrhea testing, 69.4% syphilis testing, 82.9% pregnancy testing, 77.0% chlamydia/gonorrhea prophylaxis, 47.6% emergency contraception, and 19.2% HIV prophylaxis. In multivariable logistic regression models, patients evaluated at the state's women's hospital instead of academic or community hospitals and those who sustained anal/vaginal assault instead of other assaults had a greater odds of being offered testing and prophylaxis. In some cases, older women were offered testing and prophylaxis less often than younger women. Conclusions: Testing and prophylaxis for chlamydia/gonorrhea were used much more often than prophylaxis for emergency contraception and HIV, even for patients who were anal/vaginally assaulted. Disparities in testing and prophylaxis exist by type of hospital and, in some cases, by age. Educational campaigns should be instituted to ensure that all women receive adequate testing and prophylaxis commensurate with the exposure they sustained from a sexual assault. [ABSTRACT FROM AUTHOR]

The article examines the incidence of visits for health care worker blood or body fluid exposures and HIV postexposure prophylaxis provision at Rhode Island emergency departments. It was found that the incidence of visits for exposures varied by occupation. There were also temporal trends for these visits.

The objective of this study was to elucidate factors that predicted the initiation of HIV postexposure prophylaxis (PEP) for blood or body fluid exposures evaluated at Rhode Island emergency departments (EDs). The study involved a retrospective review of patient visits to all civilian Rhode Island EDs for these exposures from 1995 to mid-2001. Multivariate logistic regression models were created to evaluate predictors of the offering and the acceptance and receipt of HIV PEP from 1996 to 2001. The search identified 3622 patients who sustained a blood or body fluid exposure. Of these, 43.8% were health care workers (HCWs) and 57.2% were not HCWs. Most (52.0%) of the exposures were nonsexual. HIV PEP was offered to 21.0% and accepted and received by 9.4% of all patients. HIV PEP was offered more often after significant exposures, exposures to known HIV-infected sources, when time elapsed after the exposure was shorter, if the patients were HCWs, adults, presented to a teaching hospital, presented during the latter years of the study, or sustained nonsexual exposures. Once offered HIV PEP, patients who were male, adult, sustained a significant exposure, knew the source was HIV infected, sustained a nonsexual exposure, or were HCWs had a greater odds of accepting and receiving HIV PEP. Even when controlling for exposure significance, HIV status, and time elapsed since the exposure, several factors such as gender and type of hospital that are unrelated to the exposure appeared to influence the initiation of HIV PEP. ED providers should ensure that these factors do not inappropriately restrict its initiation. [ABSTRACT FROM AUTHOR]

Abstract: Female Emergency Department (ED) patients were surveyed to determine their comprehension of the concept of emergency contraception (EC), to assess how often they had used EC in comparison to other forms of contraception, and to learn which patients want the ED to provide EC services. Most of the 761 respondents were aged < 35 years (62.1%), never married (42.9%), had been pregnant at least once (70.2%), had never had an abortion (76.1%), had never used EC (90.6%), and had sex with a man within the past month (70.7%). Respondents were 2.5 times more likely to have had an abortion than to have used EC; 85.3% could not correctly answer two questions that assessed comprehension of the concept of EC; 43.1% wanted the ED to offer EC, 55.6% to provide information about EC, and 52.6% to refer patients for EC. Younger patients, those who attended religious services infrequently, patients who had ever used EC, and those at risk of pregnancy were more likely to want the ED to provide EC services. [Copyright &y& Elsevier]

The article presents a study which examines the factors associated with delay to emergency department (ED) presentation and antibiotic usage for admitting human bite injuries. Of the 338 patients evaluated for a human bite, the majority had occlusional bites and only 7.7% sustained closed-fist injuries. Results revealed that most patients presented to the ED within 24 hours of their injury received antibiotics.

Background: Lack of knowledge regarding preventive health services for women might impede campaigns to expand these services in the emergency department setting. For 18-55-year-old English-speaking women visiting an urban emergency department, we aimed to: (1) Ascertain their knowledge regarding the applicability, purpose, and recommended intervals of three women's cancer screening and three contraceptive methods; and (2) Determine if patient age, race/ethnicity, medical insurance status, and current or recent usage of these methods are associated with greater or lesser knowledge about them. Methods: Emergency department-based survey on recent or current usage and knowledge about Pap smears, breast self-examinations, mammograms, condoms, birth control, and emergency contraception. Analyses included calculation of summary statistics and creation of multivariable logistic regression models. Results: Of 1,100 patients eligible for the study, 69.9% agreed to participate. Most of the participants were < age 35, white, single (never married and no partner), Catholic, and had private medical insurance. Participant's recent or current usage of a particular cancer screening or contraceptive method varied by type of method: Pap smear within the past year (69.1%), breast self-exam within the past month (45.5%), mammogram within the past year (65.7% for women age 45-55), condom usage during every episode of sexual intercourse (15.4%), current usage of birth control pills (17.8%), and ever use of emergency contraception (9.3%). The participants correctly answered 87.9% of all survey questions about condoms, 82.5% about birth control pills, 78.5% about breast self-exams, 52.9% about Pap smears, 35.4% about mammograms, and 25.0% about emergency contraception. In multivariable logistic regression models, survey participants who had private medical insurance and those who recently or currently used a given screening or contraceptive method had a greater odds of correctly answering all questions about each cancer screening or contraceptive method. Conclusion: Although these female ED patients demonstrated strong knowledge on some women's cancer screening and contraceptive methods, there were several areas of knowledge deficit. Women without private medical insurance and those who have not used a particular cancer screening or contraceptive method demonstrated less knowledge. Reduced knowledge about women's cancer screening and contraceptive methods should be considered during clinical encounters and when instituting or evaluating emergency department-based initiatives that assess the need for these methods. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: For female emergency department (ED) patients, we sought to assess the prevalence of contraceptive usage as well as the extent of contraceptive knowledge and to determine if demographic and sexual health history factors, comprehension of contraceptive methods and moral/religious opinions on contraception were associated with current usage of birth control pills (BCPs), prior usage of emergency contraception (EC) and frequency of condom usage. Methods: English-speaking female ED patients aged between 18 and 55 years at a northeastern United States urban ED were surveyed on their usage, comprehension and opinions regarding BCPs, EC and condoms. Results: Of the 539 respondents (64.6% were aged ≤35 years), most were White (63.1%), single (42.5%), Catholic (48.4%) and privately insured (55.3%). Among the 223 women at pregnancy risk [not currently pregnant, not using any form of nonsurgical birth control (except condoms) and with no prior tubal ligation or hysterectomy], about 25% were using BCPs, fewer than 10% had used EC and almost 40% never used condoms. Most women displayed good knowledge about BCPs and condoms but poor understanding about EC. In multivariate logistic regression analyses, current BCP usage among women at risk of pregnancy was associated with younger age [odds ratio (OR)=0.54; 95% confidence interval (CI)=0.37–0.79], private insurance (OR=2.52; 95% CI=1.30–4.86) and recent intercourse (OR=1.61; 95% CI=1.19–2.18). Among women at risk of pregnancy, those who had an abortion (OR=2.56; 95% CI=1.17–5.61) and those who displayed greater EC knowledge (OR=3.23; 95% CI=1.50–6.95) had greater odds of having used EC. Among all women, more frequent condom usage was associated with being younger (OR=0.57; 95% CI=0.46–0.70), having never been married (OR=0.44; 95% CI=0.28–0.68) and not having intercourse recently (OR=0.79; 95% CI=0.64–0.98). Conclusions: A high percentage of female ED patients (41.4%) were at risk of pregnancy. Demographic and sexual history factors can help identify women who might benefit from receiving referrals or education on contraceptive measures. [Copyright &y& Elsevier]

We examine ambulance runs for suspected opiate overdose from 1997 to 2002 using a Rhode Island Department of Health database. Of the 8,763 ambulance runs for overdoses, 18.6% were for suspected opiate overdoses. Most cases were males under age 54. Suspected opiate overdoses were more likely to occur in a private residence, were more frequent on Fridays and Saturdays, and peaked in incidence around 9:00 p.m. The incidence rate of suspected opiate overdose by year was similar. The study results may help identify areas for preventive intervention and demonstrate the limitation of using naloxone as a marker of opiate overdose events. [ABSTRACT FROM AUTHOR]

The Brown University AIDS Program and the Rhode Island Department of Health joined with health care practitioners, researchers, and representatives of community-based health, social service, and advocacy organizations to create comprehensive guidelines on nonoccupational HIV postexposure prophylaxis for the state of Rhode Island. These guidelines offer health care practitioners detailed advice on the evaluation and management of blood or body fluid exposures outside the health care setting, e.g., through sexual assault, consensual sex, injecting-drug use, or needlestick injuries. In these circumstances, HIV postexposure prophylaxis serves those for whom primary prevention measures have failed or were impractical or impossible. The guidelines represent the end product of coordination among private and public, academic and nonacademic, clinician and layperson groups committed to decreasing the incidence of HIV infections in the state of Rhode Island. The guidelines serve as both a resource for health care practitioners and a means of educating them on this method of HIV prevention. [ABSTRACT FROM AUTHOR]

Background: Emergency prophylaxis following needle-stick and sexual exposures includes HIV post-exposure prophylaxis, hepatitis B prophylaxis and emergency contraception. The Centers for Disease Control and Prevention endorse HIV post-exposure and hepatitis B prophylaxis for health care workers, and hepatitis B prophylaxis and emergency contraception after sexual assault. The New York State Department of Health advocates HIV post-exposure prophylaxis after sexual assault. This study compares emergency department practitioners in New York State (NYS) with those from other states in their willingness to offer emergency prophylaxis after needle-stick and sexual exposures, and their self-reported history of prescribing and using HIV post-exposure prophylaxis. Methods: The authors surveyed emergency department practitioners from across the US at the American College of Emergency Physicians 2000 Scientific Assembly. The questionnaire included clinical scenarios describing different patients who present to the emergency department within one hour of a needle-stick injury, sexual assault or consensual sexual encounter, and had questions on the practitioners' self-reported prescribing and usage of HIV post-exposure prophylaxis. For each scenario the practitioners were asked to indicate if they would offer emergency prophylaxis to different patients at varied HIV risk levels. The data were processed through SPSS 10.0. Results: Of the 600 respondents, 100 were from NYS. In the clinical scenarios, NYS practitioners were more likely than other US practitioners to offer HIV post-exposure prophylaxis for exposures to unknown and low HIV risk sources (p<0.05) and to offer hepatitis B prophylaxis in most of the sexual exposure scenarios (p<0.01). All practitioners offered HIV post-exposure and hepatitis B... [ABSTRACT FROM AUTHOR]

Adolescent substance use is a growing public health concern, particularly given rising mortality rates from drug overdose deaths. The emergency department (ED) provides a unique opportunity to screen adolescents for substance use and provide brief interventions and linkage to care. This article provides a narrative review of the current evidence for ED screening and brief interventions for adolescents with substance use and identifies important opportunities, challenges, and areas for future research. There are several validated substance use screening and assessment tools for use with adolescents that can be implemented into ED screening programs. Brief motivational interviewing interventions may reduce alcohol use, but evidence for reductions of other substances is limited due to insufficient research. Both screening and interventions are feasible and acceptable in the ED setting with the appropriate resources. Increased training and the use of emerging technology can provide emergency physicians with opportunities to incorporate these tools into practice to when treating adolescents. Linkage to outpatient care for adolescents with substance use is understudied. The research on adult patient ED interventions and linkage to care is more robust and can provide insights for future ED studies among adolescents. ED-based adolescent substance use screening and interventions are necessary, feasible, and acceptable, but understudied. Future studies, focusing on optimizing ED interventions and linkage to care, are important next steps in determining the best care for adolescents with substance use who present to the ED. [ABSTRACT FROM AUTHOR]

Reports on perspectives on new recommendations for nonoccupational HIV postexposure prophylaxis (HIV NPEP). Guidelines put in place by the U.S. Centers for Disease Control and Prevention (CDC); Interest clinicians have in the new recommendations; Advice to health care professionals on the use of antiretroviral medications for newly diagnosed HIV-infected persons.

Background: We conducted a systematic review of studies published in peer-reviewed journals on HIV screening programs conducted in pediatric emergency departments (PEDs) in the United States (US) with the objective of describing the methods, testing yields and challenges in these programs.Methods: We searched for full-text, English-language, original research articles focused on the conduct, development, initiation or implementation of any HIV screening program in a US PED through eight online databases (Pubmed (MEDLINE), Scopus, Embase, Cochrane, Web of Science, CINAHL, PsycInfo and Google Scholar) from their inception through July 2020. We also searched for articles on the websites of thirteen emergency medicine journals, 24 pediatric and adolescent health journals, and ten HIV research journals, and using the references of articles found through these searches. Data on HIV testing program components and yield of testing was extracted by one investigator independently and verified by a second investigator. Each program was summarized and critiqued.Results: Of the eight articles that met inclusion criteria, most involved descriptions of their HIV testing program, except for one that was focused on quality improvement of their program. Five described an opt-in and three an opt-out approach to HIV screening. Programs differed greatly by type of HIV test utilized and who initiated or performed testing. There were large variations in the percentage of patients offered (4.0% to 96.7%) and accepting (42.7% to 86.7%) HIV testing, and HIV seropositivity in the studies ranged from 0 to 0.6%. Five of the eight studies reported an HIV seropositivity greater than 0.1%, above Centers for Disease Control and Prevention recommended threshold for testing in a healthcare setting.Conclusions: The studies illustrate opportunities to further optimize the integration of HIV screening programs within US PEDs and reduce barriers to testing, improve efficiency of testing results and increase effectiveness of programs to identify cases. Future research should focus on advancing the methodology of screening programs beyond feasibility studies as well as conducting investigations on their implementation and longer-term sustainability. [ABSTRACT FROM AUTHOR]

Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission. Retrospective study using 2 abstractors blinded to the study aims. 474 records from NH residents transferred to the 3 EDs of Rhode Island's largest health care system from September 2015 to September 2016. NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission. Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P =.03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01–1.18). Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms. [ABSTRACT FROM AUTHOR]

Introduction: Blacks in the United States experience greater persistent pain than non-Hispanic Whites across a range of medical conditions, but to our knowledge no longitudinal studies have examined the risk factors or incidence of persistent pain among Blacks experiencing common traumatic stress exposures such as after a motor vehicle collision (MVC). We evaluated the incidence and predictors of moderate to severe axial musculoskeletal pain (MSAP) and widespread pain six weeks after a MVC in a large cohort of Black adults presenting to the emergency department (ED) for care. Methods: This prospective, multi-center, cohort study enrolled Black adults who presented to one of 13 EDs across the US within 24 hours of a MVC and were discharged home after their evaluation. Data were collected at the ED visit via patient interview and self-report surveys at six weeks after the ED visit via internet-based, self-report survey, or telephone interview. We assessed MSAP pain at ED visit and persistence at six weeks. Multivariable models examined factors associated with MSAP persistence at six weeks post-MVC. Results: Among 787 participants, less than 1% reported no pain in the ED after their MVC, while 79.8 (95% confidence interval [CI], 77.1 -- 82.2) reported MSAP and 28.3 (95% CI, 25.5 -- 31.3) had widespread pain. At six weeks, 67% (95% CI, 64, 70%) had MSAP and 31% (95% CI, 28, 34%) had widespread pain. ED characteristics predicting MSAP at six weeks post-MVC (area under the curve = 0.74; 95% CI, 0.72, 0.74) were older age, peritraumatic dissociation, moderate to severe pain in the ED, feeling uncertain about recovery, and symptoms of depression. Conclusion: These data indicate that Blacks presenting to the ED for evaluation after MVCs are at high risk for persistent and widespread musculoskeletal pain. Preventive interventions are needed to improve outcomes for this high-risk group. [ABSTRACT FROM AUTHOR]

Background: Although this has not been fully studied, videos and pictorial brochures might be equivalent methods of delivering HIV/AIDS and HIV testing information to emergency departments (ED) patients. It also is not known how well or for how long such knowledge is retained, if this information should be tailored according to patient health literacy, and if retention of this knowledge impacts future HIV testing behavior.Methods: We will conduct a multi-site, randomized, controlled, longitudinal trial among 600 English- and 600 Spanish-speaking 18-64-year-old ED patients to investigate these questions. We will stratify our sample within language (English vs. Spanish) by health literacy level (lower vs. higher) and randomly assign patients to receive HIV/AIDS and HIV testing information by video or pictorial brochure. All patients will be tested for HIV in the ED. At 12-months post-enrollment, we will invite participants to be tested again for HIV. As primary aims, we will compare the efficacy of pictorial brochures and videos in improving short-term (in ED) HIV/AIDS and HIV testing knowledge and retaining this knowledge over 12 months. We will determine if and how short-term improvement and longer-term retention of knowledge interacts with information delivery mode (pictorial brochure or video), patient health literacy level (lower or higher), and language (English or Spanish). As secondary aims, using the Information-Motivation-Behavioral Skills (IMB) model as a heuristic framework, we will measure constructs from the IMB model relevant to our study, and assess their impact on HIV re-testing behavior; we will also examine the moderating influences of information delivery mode, language, and health literacy level. In addition, we will explore simplified screening strategies to identify ED patients with lower health literacy as ways to implement a tailored approach to HIV/AIDS and HIV testing information delivery in EDs.Discussion: Study findings will guide ED-based delivery of HIV/AIDS and HIV testing information; that is, whether delivery modes (video or pictorial brochure) should be selected for patients by language and/or health literacy level. The results also will inform EDs when, how, and for whom information needs to be provided for those undergoing testing again for HIV within a one-year period.Trial Registration: ClinicalTrials.gov Identifier: NCT02284451 . Posted November 6, 2014. [ABSTRACT FROM AUTHOR]

Objectives: It is unclear if a low- or high-volume IV fluid resuscitation strategy is better for patients with severe sepsis and septic shock.Design: Prospective randomized controlled trial.Setting: Two adult acute care hospitals within a single academic system.Patients: Patients with severe sepsis and septic shock admitted from the emergency department to the ICU from November 2016 to February 2018.Interventions: Patients were randomly assigned to a restrictive IV fluid resuscitation strategy (≤ 60 mL/kg of IV fluid) or usual care for the first 72 hours of care.Measurements and Main Results: We enrolled 109 patients, of whom 55 were assigned to the restrictive resuscitation group and 54 to the usual care group. The restrictive group received significantly less resuscitative IV fluid than the usual care group (47.1 vs 61.1 mL/kg; p = 0.01) over 72 hours. By 30 days, there were 12 deaths (21.8%) in the restrictive group and 12 deaths (22.2%) in the usual care group (odds ratio, 1.02; 95% CI, 0.41-2.53). There were no differences between groups in the rate of new organ failure, hospital or ICU length of stay, or serious adverse events.Conclusions: This pilot study demonstrates that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care. Although limited by the sample size, we observed no increase in mortality, organ failure, or adverse events. These findings further support that a restrictive IV fluid strategy should be explored in a larger multicenter trial. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue including one on the need to conduct human immunodeficiency virus (HIV) screening in cancer patients and one on an HIV screening model in an emergency department settings.

Presents a letter in reply to Drs. Weinberg, Luque, and Brown's comment about using efavirenz and about nonoccupational HIV NPEP in women.

Background: Treatment for partners of patients diagnosed with sexually transmitted infections (STI), referred to as expedited partner therapy (EPT), is infrequently used in the emergency department (ED). This was a pilot program to initiate and evaluate EPT through medication-in-hand ("take-home") kits or paper prescriptions. In this study we aimed to assess the frequency of EPT prescribing, the efficacy of a randomized best practice advisory (BPA) on the uptake, perceptions of emergency clinicians regarding the EPT pilot, and factors associated with EPT prescribing. Methods: We conducted this pilot study at an academic ED in the midwestern US between August-October 2021. The primary outcome of EPT prescription uptake and the BPA impact was measured via chart abstraction and analyzed through summary statistics and the Fisher exact test. We analyzed the secondary outcome of barriers and facilitators to program implementation through ED staff interviews (physicians, physician assistants, and nurses). We used a rapid qualitative assessment method for the analysis of the interviews. Results: During the study period, 52 ED patients were treated for chlamydia/gonorrhea, and EPT was offered to 25% (95% CI 15%-39%) of them. Expedited partner therapy was prescribed significantly more often (42% vs 8%; P < 0.01) when the interruptive pop-up alert BPA was shown compared to not shown. Barriers identified in the interviews included workflow constraints and knowledge of EPT availability. The BPA was viewed positively by the majority of participants. Conclusion: In this pilot EPT program, expedited partner therapy was provided to 25% of ED patients who appeared eligible to receive it. The interruptive pop-up alert BPA significantly increased EPT prescribing. Barriers identified to EPT prescribing should be the subject of future interventions to improve provision of EPT from the emergency department. [ABSTRACT FROM AUTHOR]

Each year millions of Americans present to the emergency department (ED) for care after a motor vehicle collision (MVC); the majority (>90%) are discharged to home after evaluation. Acute musculoskeletal pain is the norm in this population, and such patients are typically discharged to home with prescriptions for oral opioid analgesics or nonsteroidal antiinflammatory drugs (NSAIDs). The influence of acute pain management on subsequent pain outcomes in this common ED population is unknown. We evaluated the effect of opioid analgesics vs NSAIDs initiated from the ED on the presence of moderate to severe musculoskeletal pain and ongoing opioid use at 6 weeks in a large cohort of adult ED patients presenting to the ED after MVC (n = 948). The effect of opioids vs NSAIDs was evaluated using an innovative quasi-experimental design method using propensity scores to account for covariate imbalances between the 2 treatment groups. No difference in risk for moderate to severe musculoskeletal pain at 6 weeks was observed between those discharged with opioid analgesics vs NSAIDs (risk difference = 7.2% [95% confidence interval: -5.2% to 19.5%]). However, at follow-up participants prescribed opioids were more likely than those prescribed NSAIDs to report use of prescription opioids medications at week 6 (risk difference = 17.5% [95% confidence interval: 5.8%-29.3%]). These results suggest that analgesic choice at ED discharge does not influence the development of persistent moderate to severe musculoskeletal pain 6 weeks after an MVC, but may result in continued use of prescription opioids. Supported by NIAMS R01AR056328 and AHRQ 5K12HS022998. [ABSTRACT FROM AUTHOR]

Background: Emergency department (ED) patients comprise a high-risk population for alcohol misuse and sexual risk for HIV. In order to design future interventions to increase HIV screening uptake, we examined the interrelationship among alcohol misuse, sexual risk for HIV and HIV screening uptake among these patients.Methods: A random sample of 18-64-year-old English- or Spanish-speaking patients at two EDs during July-August 2009 completed a self-administered questionnaire about their alcohol use using the Alcohol Use Questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the HIV Sexual Risk Questionnaire. Study participants were offered a rapid HIV test after completing the questionnaires. Binging (≥ five drinks/occasion for men, ≥ four drinks for women) was assessed and sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, dependence) were calculated using AUDIT scores. Analyses were limited to participants who had sexual intercourse in the past 12 months. Multivariable logistic regression was used to assess the associations between HIV screening uptake and (1) alcohol misuse, (2) sexual risk for HIV, and (3) the intersection of HIV sexual risk and alcohol misuse. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics and separate models for men and women were constructed.Results: Of 524 participants (55.0% female), 58.4% identified as white, non-Hispanic, and 72% reported previous HIV testing. Approximately 75% of participants reported drinking alcohol within the past 30 days and 74.5% of men and 59.6% of women reported binge drinking. A relationship was found between reported sexual risk for HIV and alcohol use among men (AOR 3.31 [CI 1.51-7.24]) and women (AOR 2.78 [CI 1.48-5.23]). Women who reported binge drinking were more likely to have higher reported sexual risk for HIV (AOR 2.55 [CI 1.40-4.64]) compared to women who do not report binge drinking. HIV screening uptake was not higher among those with greater alcohol misuse and sexual risk among men or women.Conclusions: The apparent disconnection between HIV screening uptake and alcohol misuse and sexual risk for HIV among ED patients in this study is concerning. Brief interventions emphasizing these associations should be evaluated to reduce alcohol misuse and sexual risk and increase the uptake of ED HIV screening. [ABSTRACT FROM AUTHOR]

Objective: Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk substance use.We conducted a tablet-based, anonymous, self-administered screening for substance use using a modified version of the Screening to Brief Intervention (S2BI) tool among a convenience sample of 383 patients 12–21 years presenting to an urban, academic PED from February to July 2023. Patients’ attitudes toward ED screening and interventions for substance use also were collected. The frequency and type of substance use was analyzed by age group. Ordinal logistic regression was used to identify characteristics associated with higher-risk use (monthly or more substance use) and lower-risk use (past year use), as compared to no past year use.Among 14-17-year-olds (n = 144), 38% reported substance use in the past year; 25% had higher-risk use. Among 18–21-year-olds (n = 172), 67% reported substance use in the past year; 48% had higher-risk use. Alcohol, cannabis, and tobacco were most commonly used. Substance use was rare for 12–13-year-olds. Compared to youth 14–17 years, youth 18–21 years were more likely to have either higher-risk use (aOR 3.81, 95% CI (2.24–6.47)) or lower-risk use (aOR 2.74 (1.41–5.35)), rather than no use. Compared to Asian patients, Non-Hispanic White patients (aOR 5.23 (1.07–25.66)) and Hispanic patients (aOR 3.18 (1.06–9.58)) were more likely to have higher-risk use than no use. Most patients reported that it was important for youth to be asked about substance use in the ED and to be offered help for substance use.Youth substance use was common in this urban, academic PED, and many patients reported higher-risk use. These findings support future research to determine the best practices for ED substance use screening and ED-based interventions for youth.Methods: Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk substance use.We conducted a tablet-based, anonymous, self-administered screening for substance use using a modified version of the Screening to Brief Intervention (S2BI) tool among a convenience sample of 383 patients 12–21 years presenting to an urban, academic PED from February to July 2023. Patients’ attitudes toward ED screening and interventions for substance use also were collected. The frequency and type of substance use was analyzed by age group. Ordinal logistic regression was used to identify characteristics associated with higher-risk use (monthly or more substance use) and lower-risk use (past year use), as compared to no past year use.Among 14-17-year-olds (n = 144), 38% reported substance use in the past year; 25% had higher-risk use. Among 18–21-year-olds (n = 172), 67% reported substance use in the past year; 48% had higher-risk use. Alcohol, cannabis, and tobacco were most commonly used. Substance use was rare for 12–13-year-olds. Compared to youth 14–17 years, youth 18–21 years were more likely to have either higher-risk use (aOR 3.81, 95% CI (2.24–6.47)) or lower-risk use (aOR 2.74 (1.41–5.35)), rather than no use. Compared to Asian patients, Non-Hispanic White patients (aOR 5.23 (1.07–25.66)) and Hispanic patients (aOR 3.18 (1.06–9.58)) were more likely to have higher-risk use than no use. Most patients reported that it was important for youth to be asked about substance use in the ED and to be offered help for substance use.Youth substance use was common in this urban, academic PED, and many patients reported higher-risk use. These findings support future research to determine the best practices for ED substance use screening and ED-based interventions for youth.Results: Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk substance use.We conducted a tablet-based, anonymous, self-administered screening for substance use using a modified version of the Screening to Brief Intervention (S2BI) tool among a convenience sample of 383 patients 12–21 years presenting to an urban, academic PED from February to July 2023. Patients’ attitudes toward ED screening and interventions for substance use also were collected. The frequency and type of substance use was analyzed by age group. Ordinal logistic regression was used to identify characteristics associated with higher-risk use (monthly or more substance use) and lower-risk use (past year use), as compared to no past year use.Among 14-17-year-olds (n = 144), 38% reported substance use in the past year; 25% had higher-risk use. Among 18–21-year-olds (n = 172), 67% reported substance use in the past year; 48% had higher-risk use. Alcohol, cannabis, and tobacco were most commonly used. Substance use was rare for 12–13-year-olds. Compared to youth 14–17 years, youth 18–21 years were more likely to have either higher-risk use (aOR 3.81, 95% CI (2.24–6.47)) or lower-risk use (aOR 2.74 (1.41–5.35)), rather than no use. Compared to Asian patients, Non-Hispanic White patients (aOR 5.23 (1.07–25.66)) and Hispanic patients (aOR 3.18 (1.06–9.58)) were more likely to have higher-risk use than no use. Most patients reported that it was important for youth to be asked about substance use in the ED and to be offered help for substance use.Youth substance use was common in this urban, academic PED, and many patients reported higher-risk use. These findings support future research to determine the best practices for ED substance use screening and ED-based interventions for youth.Conclusion: Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk substance use.We conducted a tablet-based, anonymous, self-administered screening for substance use using a modified version of the Screening to Brief Intervention (S2BI) tool among a convenience sample of 383 patients 12–21 years presenting to an urban, academic PED from February to July 2023. Patients’ attitudes toward ED screening and interventions for substance use also were collected. The frequency and type of substance use was analyzed by age group. Ordinal logistic regression was used to identify characteristics associated with higher-risk use (monthly or more substance use) and lower-risk use (past year use), as compared to no past year use.Among 14-17-year-olds (n = 144), 38% reported substance use in the past year; 25% had higher-risk use. Among 18–21-year-olds (n = 172), 67% reported substance use in the past year; 48% had higher-risk use. Alcohol, cannabis, and tobacco were most commonly used. Substance use was rare for 12–13-year-olds. Compared to youth 14–17 years, youth 18–21 years were more likely to have either higher-risk use (aOR 3.81, 95% CI (2.24–6.47)) or lower-risk use (aOR 2.74 (1.41–5.35)), rather than no use. Compared to Asian patients, Non-Hispanic White patients (aOR 5.23 (1.07–25.66)) and Hispanic patients (aOR 3.18 (1.06–9.58)) were more likely to have higher-risk use than no use. Most patients reported that it was important for youth to be asked about substance use in the ED and to be offered help for substance use.Youth substance use was common in this urban, academic PED, and many patients reported higher-risk use. These findings support future research to determine the best practices for ED substance use screening and ED-based interventions for youth. [ABSTRACT FROM AUTHOR]

Introduction: Urolithiasis causes severe acute pain and is commonly treated with opioid analgesics in the emergency department (ED). We examined opioid analgesic use after episodes of acute pain. Methods: Using data from a longitudinal trial of ED patients with urolithiasis, we constructed multivariable models to estimate the adjusted probability of opioid analgesic use 3, 7, 30, and 90 days after ED discharge. We used multiple imputation to account for missing data and weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. We used weighted multivariable regression to compare longitudinal opioid analgesic use for those prescribed vs not prescribed an opioid analgesic at discharge, stratified by reported pain at ED discharge. Results: Among 892 adult ED patients with urolithiasis, 79% were prescribed an opioid analgesic at ED discharge. Regardless of reporting pain at ED discharge, those who were prescribed an opioid analgesic were significantly more likely to report using it one, three, and seven days after the visit in weighted multivariable analysis. Among those who were not prescribed an opioid analgesic, an estimated 21% (not reporting pain at ED discharge) and 30% (reporting pain at discharge) reported opioid analgesic use at day three. Among those prescribed an opioid analgesic, 49% (no pain at discharge) and 52% (with pain at discharge) reported using an opioid analgesic at day three. Conclusion: Urolithiasis patients who received an opioid analgesic at ED discharge were more likely to continue using an opioid analgesic than those who did not receive a prescription at the initial visit, despite the time-limited nature of urolithiasis. [ABSTRACT FROM AUTHOR]

Because of the multitude of financial, health, and social problems associated with prescription opioid misuse, effective methods of identifying older adults who are misusing these medications are needed. We conducted a pilot investigation to determine the prevalence of previous and current prescription opioid use among older adults visiting the Rhode Island Hospital Emergency Department and their need for opioid misuse interventions. Among 88 randomly selected older adults (> 65 years of age) presenting to the ED with sub-critical illness or injury, 19% (95% CI: 11-27%) were current opioid users and 6% (95% CI: 4-8%) would require an intervention for prescription opioid misuse. We identified problems of improper acquisition, diversion, provider refusal to prescribe opioids, hoarding, and inappropriate use of opioids among this population. Emergency medicine clinicians should query their older adult patients about prescription opioid misuse and associated problematic behaviors. [ABSTRACT FROM AUTHOR]

Introduction. This pilot study assessed the prevalence of physiologic and behavioral adverse effects among adolescent (13-17 years) and adult (18-25 years) emergency department patients who reported energy drink and/or caffeinated-only beverage use within the 30 days prior to emergency department presentation. It was hypothesized that energy drink users would report more adverse effects than those who used only traditional caffeinated beverages such as coffee, tea, or soft drinks. Methods. This cross-sectional pilot study was conducted in two urban emergency departments, one adult and one pediatric. Eligible patients were enrolled during a 6-week period between June and August 2010. Participants completed a tablet computer-based, self-administered, anonymous questionnaire about their past 30-day energy drink and/or caffeinated-only beverage use, substance use, and experience of 10 physiologic and 10 behavioral symptoms. Multivariable logistic regression and negative binomial regression models, adjusted for age, gender, and substance use, were created to compare the occurrence of each adverse effect between energy drink and caffeinated-only beverage users. Odds ratios (ORs) and incidence rate ratios (IRRs) were estimated. Results. Of those enrolled, 53.3% reported consuming energy drinks, 39.1% caffeinated-only beverages, and 7.6% no energy drinks or caffeinated-only beverages within the past 30 days. In multivariable logistic regression models, energy drink users were more likely than caffeinated-only beverage users to report having 'gotten into trouble at home, school, or work' in the past 30 days (OR: 3.12 [1.24-7.88]). In the negative binomial regression multivariable models, more behavioral effects were reported among drug users (IRR: 1.50 [1.18-1.93]), and more physiologic effects were reported among tobacco users (IRR: 1.42 [1.13-1.80]) and females (IRR: 1.48 [1.21-1.80]), but not among energy drink users. Conclusions. Energy drink users and substance users are more likely to report specific physiologic and behavioral adverse effects. Emergency department clinicians should consider asking patients about energy drink and traditional caffeine usage and substance use when assessing patient symptoms. [ABSTRACT FROM AUTHOR]

Non-pharmaceutical fentanyl and its analogs have driven striking increases in opioid-associated overdose deaths. These highly potent opioids can be found at low concentrations in biological specimens. Little is known regarding the concentrations of these substances among survivors of non-fatal overdoses. In a locale where fentanyl is responsible for the majority of non-fatal opioid overdoses, we compared the concentration of fentanyl in blood to naloxone dosing in the presence and absence of a concurrent sedative-hypnotic exposure. In this pilot study, we enrolled adult patients presenting to the emergency department (ED) who: (1) arrived after an overdose requiring naloxone for the reversal of respiratory depression; and (2) who required venipuncture or intravenous access as part of their clinical care. Blood specimens (n = 20) underwent comprehensive toxicology testing, including the quantitation of fentanyl, fentanyl analogs, and naloxone, as well as the detection of common sedative-hypnotics and a wide range of other illicit and pharmaceutical substances. We then compared fentanyl concentrations to naloxone dosing in participants with and without a concomitant sedative-hypnotic exposure. Nineteen of twenty participants (95%) were exposed to fentanyl prior to their overdose; the remaining participant tested positive for heroin metabolites. No participants reported pharmaceutical fentanyl use. Fentanyl analogs – acetylfentanyl or carfentanil – were present in three specimens. In 11 cases, fentanyl and its metabolites were the only opioids identified. Among the fentanyl-exposed, blood concentrations ranged from <0.1–19 ng/mL with a mean of 6.2 ng/mL and a median of 3.6 ng/mL. There was no relationship between fentanyl concentration and naloxone dose administered for reversal. We detected sedative-hypnotics (including benzodiazepines, muscle relaxants, and antidepressants) in nine participants. Among the sedative-hypnotic exposed, fentanyl concentrations were lower, but naloxone dosing was similar to those without a concomitant exposure. In this study, we found that: 1) fentanyl was present in the blood of nearly all participants; 2) fentanyl concentrations were lower among study participants with concomitant sedative-hypnotic exposure; and 3) the dose of naloxone administered for overdose reversal was not associated with the measured fentanyl concentration in blood specimens. Our results underscore the role that tolerance and concomitant drug exposure play in the precipitation and resuscitation of management of opioid overdose. [ABSTRACT FROM AUTHOR]

Background: Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain.Objectives: Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis.Methods: We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge.Results: Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90.Conclusions: Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications. [ABSTRACT FROM AUTHOR]

Background: Individuals aged 65 and older face unique barriers to adoption of telehealth, and the coronavirus disease 2019 pandemic has provided a "natural experiment" in how to meet the health needs of older patients remotely. Physician perspectives on practical considerations surrounding telehealth adoption, motivations of use, and reasons for nonuse are necessary to inform the future of healthcare delivery. The objective is to understand the experiences of physicians using telemedicine for older patients. Methods: From September to November 2020, we conducted 30‐min semi‐structured interviews using purposeful sampling to identify and enroll participants from diverse settings. We included 48 U.S.‐based physicians (geriatrician, n = 18, primary care, n = 15, emergency, n = 15) from all geographic regions, rural–urban and academic/community settings. Audio‐recorded interviews were professionally transcribed and analyzed using framework analysis. Major themes and subthemes were identified. Results: Participants had a median (interquartile range) age of 37.5 (34–44.5), 27 (56%) were women. Five major themes emerged: (1) telehealth uptake was rapid and iterative, (2) telehealth improved the safety of medical care, (3) use cases were specialty‐specific (for geriatricians and primary care physicians telehealth substituted for in‐person visits; for emergency physicians it primarily supplemented in‐person visits), (4) physicians altered clinical care to overcome older patient barriers to telehealth use, and (5) telehealth use among physicians declined in mid‐April 2020, due primarily to patient needs and administrator preferences, not physician factors. Conclusion: In this qualitative analysis, physicians reported a rapid, iterative uptake of telehealth and attenuation of use as coronavirus disease 2019 prevalence declined. Physician experiences during the pandemic can inform interventions and policies to help buoy telehealth for ongoing healthcare delivery and ensure its accessibility for older Americans. [ABSTRACT FROM AUTHOR]

Background: Respiratory variation in carotid artery peak systolic velocity (ΔVpeak) assessed by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means to predict fluid responsiveness. We aimed to evaluate the ability of carotid ΔVpeak as assessed by novice physician sonologists to predict fluid responsiveness. Methods: This study was conducted in 2 intensive care units. Spontaneously breathing, nonintubated patients with signs of volume depletion were included. Patients with atrial fibrillation/flutter, cardiogenic, obstructive or neurogenic shock, or those for whom further intravenous (IV) fluid administration would be harmful were excluded. Three novice physician sonologists were trained in POCUS assessment of carotid ΔVpeak. They assessed the carotid ΔVpeak in study participants prior to the administration of a 500 mL IV fluid bolus. Fluid responsiveness was defined as a ≥10% increase in cardiac index as measured using bioreactance. Results: Eighty-six participants were enrolled, 50 (58.1%) were fluid responders. Carotid ΔVpeak performed poorly at predicting fluid responsiveness. Test characteristics for the optimum carotid ΔVpeak of 8.0% were: area under the receiver operating curve = 0.61 (95% CI: 0.48-0.73), sensitivity = 72.0% (95% CI: 58.3-82.56), specificity = 50.0% (95% CI: 34.5-65.5). Conclusions: Novice physician sonologists using POCUS are unable to predict fluid responsiveness using carotid ΔVpeak. Until further research identifies key limiting factors, clinicians should use caution directing IV fluid resuscitation using carotid ΔVpeak. [ABSTRACT FROM AUTHOR]

Objectives: Inferior vena cava collapsibility (cIVC) measured by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means of assessing fluid responsiveness. We aimed to prospectively evaluate the performance of a 25% cIVC cutoff value to detect fluid responsiveness among spontaneously breathing intensive care unit (ICU) patients when assessed with POCUS by novice versus expert physician sonologists. Methods: Prospective observational study of spontaneously breathing ICU patients. Fluid responsiveness was defined as a ≥10% increase in cardiac index following a 500 mL fluid bolus, measured by bioreactance. Novice sonologist measured cIVC with POCUS. Their measurements were later compared to an expert physician sonologist who independently reviewed the POCUS images and assessed cIVCs. Results: Of the 85 participants, 44 (52%) were fluid responders. A 25% cIVC cutoff value performed better when assessed by expert sonologists than novice physician sonologists (receiver--operator characteristic curve, ROC = 0.82 [0.74-0.88] vs ROC = 0.69 [0.60-0.77]). Conclusions: A 25% cIVC cutoff value measured by POCUS detects fluid responsiveness. However, the experience of the physician sonologist affects test performance and should be considered when interpreting and clinically using cIVC to direct intravenous fluid resuscitation. [ABSTRACT FROM AUTHOR]